Diagnosis and Management of the Patulous Eustachian Tube

Transnasal Fluoroscopic-Guided Eustachian Tube Obliteration With a Liquid Embolic Agent for a Recurrent Cerebrospinal Fluid Leak After Translabyrinthine Schwannoma Surgery: A Case Series

OBJECTIVE

Postoperative cerebrospinal fluid (CSF) leak after schwannoma surgery occurs in up to 10% of patients. Conventional surgical treatment including fat and muscle packing can prove unsuccessful. We describe a minimally invasive, imaging-guided approach to CSF fistula treatment.

PATIENTS

We describe two patients and three procedures with recurrent CSF rhinorrhea after translabyrinthine vestibular or facial nerve schwannoma surgery. First-line procedures including CSF diversion and repeat middle ear packing failed to close the leaks.

INTERVENTION

Endonasal endoscopic, fluoroscopic-guided obliteration of the Eustachian tube with n -butyl cyanoacrylate.

MAIN OUTCOME MEASURE

Recurrence of a CSF leak.

RESULTS

After treatment, the CSF leak ceased with no recurrence. One patient's facial nerve dysfunction worsened after the procedure.

CONCLUSIONS

This case series highlights a recently described technique of imaging-guided Eustachian tube obliteration using liquid embolic agent. The procedure was effective in treating recurrent CSF leaks but might cause facial nerve dysfunction.

Postoperative course of Eustachian tube plug surgery with Kobayashi plug

OBJECTIVE

To investigate its effectiveness and safety and clarify the postoperative course of Kobayashi plug surgery for refractory patulous Eustachian tubes.

METHODS

This retrospective study included 83 patients diagnosed with a patulous Eustachian tube who received Kobayashi plug surgery at our hospital.

RESULTS

At 1 month postoperatively, the success rate was 74.0 %; at 3 months, it was 67.1 %; at 6 months, it was 65.0 %; and at 12 months it was 65.2 %. At 6 months, otitis media with effusion (OME) was observed in 12.5 % of cases, and residual tympanic membrane perforation was observed in 5.0 %. Ventilation tube placement was performed in 10 cases, and eight cases required revision surgery. During the course, plugs were removed in four cases. Median values of patulous Eustachian Tube Handicap Inventory-10 (PHI-10) at 1, 3, 6, and 12 months postoperatively were 14, 16, 16, and 20, respectively. PHI-10 significantly improved at all the time points after surgery than before surgery (median 33).

CONCLUSION

The Kobayashi plug surgery is safe and effective for refractory patulous Eustachian tubes over the long term. At 6 months postoperatively, there were few cases of OME, and the symptoms also stabilized.

Bayesian nested frailty model for evaluating surgical management of patulous Eustachian tube dysfunction

BACKGROUND

The nested frailty model, a random effects survival model that can accommodate data clustered at two hierarchical levels, has been rarely used in practice. We aimed to evaluate the utility of the Bayesian nested frailty modeling approach in the context of a study to examine the effects of various surgical procedures for patients with patulous Eustachian tube dysfunction (PETD).

METHODS

A nested frailty model was employed to account for the correlation between each pair of ears within patients and the correlation between multiple event times within each ear. Some patients underwent multiple different surgical treatments in their affected ears. We incorporated two nested lognormal frailties into the Cox proportional hazards model. The Bayesian Monte Carlo Markov Chain approach was utilized. We examined the consequences of ignoring a multilevel structure of the data.

RESULTS

The variances of patient-level and ear-level random effects were both found to be significant in the nested frailty model. Shim insertion and patulous Eustachian tube reconstruction using Alloderm or cartilage were associated with a lower risk of recurrence of PETD symptoms than calcium hydroxyapatite injection.

CONCLUSIONS

Bayesian nested frailty models provide flexibility in modeling hierarchical survival data and effectively account for multiple levels of clustering. Our study highlights the importance of accounting for all levels of hierarchical clustering for valid inference.

GLP-1 Receptor Agonist Induced Eustachian Tube Dysfunction: Database and Systematic Review of Otolaryngologic Adverse Events

INTRODUCTION

GLP-1 receptor agonists (GLP-1 RAs) have gained traction in the management of obesity. There is limited literature on the implications of GLP-1 RAs in the field of otolaryngology.

METHODS

We explore the association between GLP-1 RAs with eustachian tube dysfunction (ETD) and patulous ETD (PETD) by review of cases, literature, and the FDA adverse event database (FAERS). We also performed a systematic review using the PRISMA guidelines.

RESULTS

We present autophony and aural fullness following GLP-1 agonist use. In both cases, nasal endoscopy confirmed significant loss of tissue bulk of the anterior and posterior ET cushions. The total number of adverse events (AEs) with GLP-1 RAs was 97,237. The proportion of otologic AEs was 958 (0.99%): 515 hypoacusis, 203 vertigo, 97 deafness, 93 tinnitus, 22 ear pain, 21 motion sickness, 5 hyperacusis, 2 ear fullness, and 0 autophony. The largest number of potential ETD-related AEs occurred with dulaglutide (417). The greatest proportion of potential ETD-related AEs occurred with exenatide (1.52%) followed by semaglutide (1.17%) and liraglutide (1.16%). The systematic review using PRISMA guidelines yielded 1,490 initial articles, of which 937 were screened and 10 met the inclusion criteria. The top 3 identified otologic side effects included nasopharyngitis, sinusitis, unspecified dizziness.

DISCUSSION

Ear complaints due to GLP-1 RAs have been reported previously. However, this is the first report of PETD associated with GLP-1 RAs. While literature on GLP-1 RAs and PETD is currently limited, the mechanism is well established as reports of PETD after rapid weight loss, especially in bariatric surgery, are well known. Given the rising use of GLP-1 RAs for weight loss, clinicians should be vigilant in screening for otolaryngologic side effects, especially PET, in this population.

CONCLUSION

Otolaryngologists should be aware and monitor for possible otolaryngologic side effects, particularly PETD, with GLP-1 RA use.

Diagnosis and treatment of patulous eustachian tube

Symptoms of patulous Eustachian Tube (PET) were first described by Jago in 1858 and reported by Schwartze in 1864, recognizing PET as a clinical entity. This review summarizes the causes, epidemiology, diagnosis, and treatment of PET, with a particular emphasis on diagnosis and treatment, detailing the diagnostic criteria and silicone plug (Kobayashi plug) surgery proposed or developed in Japan. PET is often linked to weight loss from chronic illnesses, dieting, anorexia nervosa, hemodialysis, and bariatric surgery. It is also associated with pregnancy, oral contraceptive use, nasopharyngeal and muscular atrophy or scarring, and neuromuscular diseases. Interestingly, many PET cases lack an identifiable cause. The prevalence of PET ranges from 0.3 % to 7.0 %, with a higher incidence in females and typically occurring in adolescents and adults. Diagnosis relies on a combination of clinical history, physical examination, ET function test, and imaging. The Japan Otological Society (JOS) proposed standardized diagnostic criteria, where a "definite PET" diagnosis requires all three criteria (aural symptoms, tubal obstruction procedures, and objective findings), while "possible PET" requires two. Treatment includes conservative and surgical interventions. For persistent and severe cases that do not improve with conservative treatments, surgical options are explored. These surgical procedures are classified by the type of intervention, which includes tympanic membrane manipulation (such as tympanostomy tube insertion and mass loading of the tympanic membrane), plug surgery, ET injection, shim surgery, tuboplasty, and ET closure. The Kobayashi plug, a 23 mm long silicone plug, is specifically designed for PET treatment. Indications for its use include "definite PET," a PHI-10 score of 26 or higher, and lack of improvement after six months of conservative treatment. Preoperative evaluations include CT scans to assess ET patency and confirm the bony portion. Surgery, mostly performed under local anesthesia, involves inserting the plug into the ET via a myringotomy, ensuring the correct size and position with endoscopic guidance. In conclusion, PET is a challenging condition with diverse etiologies and symptoms. Effective management requires a comprehensive diagnostic approach and tailored treatment plans, with the Kobayashi plug offering a promising solution for refractory cases. Further research and advancements in diagnostic techniques and therapeutic interventions will continue to enhance the management of PET.

First Investigation of a Eustachian Tube Stent in Experimentally Induced Eustachian Tube Dysfunction

Unmet needs in the treatment of chronic otitis media and Eustachian tube dysfunction (ETD) triggered the development of stents for the Eustachian tube (ET). In this study, for the first time, stents were placed in an artificially blocked ET to evaluate stent function. Eight adult female sheep were injected with stabilized hyaluronic acid (HA) on both sides to induce ETD. Subsequently, a tapered nitinol ET stent was inserted on one side, and animals were examined bilaterally by endoscopy, tympanometry, cone beam computed tomography, and final histology. Seven of the stents were placed in the desired cartilaginous portion of the ET. At the end of the study, one stented side appeared slightly open; all other ET orifices were closed. Tympanometry revealed re-ventilation of the middle ear in four out of seven correctly stented animals within 3 to 6 weeks after stent insertion. The major amount of HA was found at the pharyngeal orifice of the ET anterior to the stent. Thus, the stent position did not completely align with the HA position. While a functional analysis will require refinement of the experimental setup, this study provides first promising results for stent insertion in a sheep model of ETD.

Patulous Eustachian tube: Deep breath for a diagnosis

Significance Statement: Eustachian tube disorders are common outpatient otologic presentations that can present a diagnostic challenge due to overlapping symptoms. This article will focus on patulous Eustachian tube, how the symptoms can overlap with those of Eustachian tube dysfunction, and the diagnostic insight offered by a close inspection of the tympanic membrane.

Mid-term evaluation of the surgical management of patulous Eustachian tube dysfunction: a STROBE observational study

INTRODUCTION

Patulous Eustachian tube (PET) is a condition affecting approximately 0.3% to 6.6% of the population, with autophony being the predominant complain. The management of PET lacks a well-defined standard in the literature as no effective medical treatments have been documented but various surgical options are available. This study aims to report mid-term outcomes following surgical management of PET.

MATERIALS AND METHODS

All patients who underwent surgical intervention for PET between September 2017 and June 2022 were enrolled. Data encompassing general demographics, quality of life (GBI), and procedure-specific data were collected.

RESULTS

A total of 30 PET cases (in 19 patients) underwent surgical intervention including 9 injections of hyaluronic acid, 13 fat injections, 6 endoscopic shim insertions, 1 cartilage graft, and 1 injection of hydroxy apatite. After an average follow-up of 22 ± 14 months, 16 cases (53%) achieved complete symptom relief, while 8 cases (26.6%) reported partial relief. Additionally, 11(36%) cases required multiple surgeries. No specific surgical technique demonstrated superiority. Quality of life improved in 77% of cases based on 10 out of 13 GBI collected. Recurrence of PET symptoms occurred on average 10.6 ± 9.7 months after initial surgery, with an estimated global risk of 75% at 3 years. Transient serous otitis media was observed in only 4 cases (13.3%).

CONCLUSION

Surgical intervention for PET was found to be effective, achieving complete symptom relief in 53% of cases and significantly improving quality of life 2 years post-surgery. However, a substantial portion of cases necessitated one or more re-interventions. The durability of effectiveness appears to diminish over time.

A manual of Eustachian tube function tests-illustration of representative test results obtained from healthy subjects and typical disorders with suggestion of the appropriate test method of choice

In the 19th century, Politzer devised a method to measure passage of the Eustachian tube (ET) by pressurizing the nasopharyngeal cavity, which marked the beginning of the ET function test. Since then, various examination methods have been developed. While ET function testing is important, recent advancements in diagnostic imaging and treatments have renewed interest on its importance. In Japan, the main objective methods used for examining ET function include tubotympanoaero-dynamic graphy (TTAG), sonotubometry, and the inflation-deflation test. The Japan Otological Society (JOS) Eustachian Tube Committee has proposed a manual of ET function tests, which presents typical patterns of the normal ear and typical diseases and suggests the ET function test of choice for each disease. However, the diagnosis of each disease should be made based on a comprehensive history and various examination findings, with ET function tests playing a supplemental role in the diagnosis.

Tympanic membrane findings and Eustachian tube function after transtympanic plugging for the chronic patulous Eustachian tube

OBJECTIVE

To evaluate Eustachian tube (ET) function after Kobayashi plug surgery based on the tympanic membrane (TM) findings and active opening (AO) of the ET assessed with sonotubometry.

SUBJECTS AND METHODS

A retrospective survey of medical records identified 74 ears of 66 patients with patulous ET (PET) received transtympanic insertion of the Kobayashi plug. Excluding the six ears (6 patients) with abnormal preoperative TM, sixty-eight ears of 60 patients were found to have normal TM preoperatively. Among these 68 ears, there were 51 ears in which sonotubometry was performed both before and after surgery to evaluate whether the AO of the ET was positive or not.

RESULTS

Out of the 68 ears with normal preoperative TM, 52 ears (76.5%) were judged successful (sum of complete relief and significant improvement). The postoperative TM was normal in 41 ears (60.3%), while 27 ears (39.7%) had abnormal TM findings postoperatively. The success rate was 75.6% (31/41) in ears with normal postoperative TM, while it was 77.8% (21/27) in ears with abnormal TM. Success in maintaining normal postoperative TM was found in 45.6% (31/68) of the total ears treated. Out of the 51 ears in which sonotubometry was performed both before and after surgery, AO was preoperatively positive in 88.2% of the ears (45/51), while it was positive in 64.7% (33/51) postoperatively. In thirty-four ears with normal TM postoperatively, AO was positive in 24 ears (70.6%), while it was positive in 9 out of 17 ears (52.9%) with abnormal postoperative TM. The success rate was 70.6% (36/51) for the 51 ears in which AO was assessed both pre- and postoperatively, and it was 66.7% (22/33) in ears with positive AO postoperatively, while it was 77.8% (14/18) in ears without AO postoperatively. The incidence of ears either having normal postoperative TM or positive AO postoperatively was 84.3% (43/51). Abnormal postoperative TM findings without effectiveness were found in 8.8% (6/68).

CONCLUSION

The obstructive dysfunction of the ET is a calculated risk but did not occur in most ears after plugging with the Kobayashi plug. Therefore, routine insertion of the VT at the same time as the initial surgery is not recommended for PET cases that are adequately followed up.

The Prevalence of Hearing Symptoms Associated With Patulous Eustachian Tube Dysfunction Following Bariatric Surgery at King Khalid University Hospital, Saudi Arabia

Background A patulous Eustachian tube (PET) is defined as a persistent tubal opening, which affects 0.3-6.6% of the population, with a female preponderance. PET is caused by the loss of subcutaneous adipose tissue enclosing the cartilaginous portion of the Eustachian tube (Ostmann's pad) as a result of acute, rapid, and substantial loss of weight which occurs during bariatric surgery. The most common complaint of PET is autophony, in which patients hear their own voices or breaths, with additional symptoms including crackling sounds, tinnitus, and aural congestion. In this study, we aimed to determine the prevalence of symptoms associated with PET dysfunction subsequent to bariatric surgery at King Khalid University Hospital (KKUH). Methodology A cross-sectional study was conducted at KKUH, Saudi Arabia. The presence of symptoms consistent with the diagnosis of PET dysfunction was assessed through in-person and telephonic interviews of bariatric surgery patients using a standardized questionnaire. Results A total of 450 patients were evaluated. The preoperative body mass index (BMI) of evaluated patients ranged from 28 to 117 kg/m2 (mean = 46.07 kg/m2), with no significant difference between symptomatic and asymptomatic groups (p = 0.303). The postoperative BMI ranged from 16 to 100 kg/m2 (mean = 29.37 kg/m2), with no significant difference between symptomatic and asymptomatic groups (p = 0.263). Hypertension was the most prevalent comorbid condition (12.2%), followed by diabetes (9.3%). In total, 91 (20.22%) patients exhibited symptoms (aural fullness and autophony) compatible with patent auditory tube dysfunction. Conclusions Overall, 20.22% of the bariatric surgery patients in our study sample displayed symptoms consistent with patulous auditory tubal dysfunction. The preoperative and postoperative BMI of symptomatic and asymptomatic patients did not differ significantly. To improve patient outcomes and satisfaction following bariatric surgery hearing symptoms associated with PET need to be included in postoperative follow-ups after bariatric surgery.

Place of Tubomanometry in Patulous Eustachian Tube Diagnosis

OBJECTIVE

The aim of our study was to describe the diagnostic performances of tubomanometry (TMM) and to determine tubomanometric parameter thresholds for the diagnosis of patulous eustachian tube (PET).

STUDY DESIGN

We performed a retrospective, monocentric study, including patients treated for PET vs control group.

SETTING

This study was performed at the Otolaryngology Department of a tertiary-care hospital in the south of France.

METHODS

We collected epidemiologic and clinical data, as well as adjusted opening latency index ("R"-index), rhinopharyngeal pressure threshold of tubal opening (Po), and velar contraction index (IVC) on TMM. Receiver operating characteristic (ROC) curves were used for determination of R index and Po thresholds.

RESULTS

Twenty-one patients (26 patulous ears) and 14 controls (24 normal ears) were included. The R index values and Po values were significantly lower in the PET group vs controls (0.46 vs 0.80, respectively; P < .05 for R index and 13.89 vs 26.42 mbar, respectively; P < .05 for Po). No significant difference was reported between the 2 groups on IVC measurement (P = .784). After ROC curve analysis, R index was the most discriminating factor to classify PET patients with 89% specificity and 76% sensitivity with a threshold ≤0.6. Po value ≤10 mbar could support this diagnosis with more than 83% specificity.

CONCLUSION

TMM is a reliable noninvasive method for positive diagnosis of PET. TMM could provide an accurate positive PET diagnosis and an objective evaluation for PET management.

Prospective Assessment of Otologic Adverse Events due to Teprotumumab: Preliminary Results

OBJECTIVE

To assess a series of patients receiving teprotumumab therapy and objectively quantify the rates of otologic adverse events.

STUDY DESIGN

A prospective cohort study of adult patients receiving teprotumumab between May 2020 and January 2022.

SETTING

Tertiary referral center.

METHODS

Prior to treatment initiation, an ototoxicity-specific audiometric battery was completed, which included conventional audiometry (frequencies 250-8000 Hz), ultrahigh-frequency audiometry (9000-20,000 Hz), tympanometry, speech discrimination scores, and distortion product otoacoustic emissions (DPOAEs). Testing was then repeated after treatment completion.

RESULTS

In total, 35 patients were recruited, with a median (range) age of 48.5 years (21-74), and 8 (22.8%) were male. The most common subjective symptom reported was a hearing decline (25.7%), followed by aural fullness (17.1%) and tinnitus (14.3%). Fourteen patients had both pre- and posttreatment audiometric data. Among them, 3 patients (21.4%) were found to have changes in standard frequency audiometry, and 10 (71.4%) had changes in high-frequency audiometry, with 2 patients having changes in both. Less than half (n = 5) of the 11 patients with changes in standard or high-frequency pure tone hearing noted subjective hearing decline. Changes in DPOAE were noted in 4 patients out of 13 (30.7%). Two patients discontinued treatment due to hearing decline. Finally, 3 patients (8.6%) were diagnosed with patulous eustachian tube (PET) by an otolaryngologist, and another 3 patients are suspected to have PET based on symptom description during ophthalmologic follow-up.

CONCLUSION

In our cohort, a high incidence of otologic symptoms was found to be associated with teprotumumab usage. Subjective hearing decline, changes in ultrahigh-frequency hearing as well as eustachian tube dysfunction may be encountered and suggest the potential ototoxicity of teprotumumab.

Transient patulous eustachian tube in severe anorexia nervosa: A prospective observational study

Objectives

To understand the presence of transient autophony symptoms in patients being treated for severe anorexia nervosa (AN), and whether those symptoms were due to patulous eustachian tube (PET).

Methods

A prospective observational study was performed in patients requiring admission for treatment of severe AN. All enrolled patients completed The Eustachian Tube Dysfunction Questionnaire (ETDQ-7) and were screened for symptoms of autophony. If patients reported autophony and had a score of ≥14.5 on the ETDQ-7 they were asked to undergo comprehensive audiological testing and an evaluation with an otolaryngologist.

Results

Of the 73 patients enrolled in the study, 35 patients (44%) reported autophony and 36 (49%) scored 14.5 or higher on the ETDQ-7. Of the 16 (22%) patients who had both autophony and an ETDQ-7 score of 14.5 or higher, 7 patient s (representing 11 symptomatic ears) underwent evaluations by audiology and otolaryngology. Every evaluation of a symptomatic ear revealed objective evidence of PET. Nine of 11 (81.8%) symptomatic ears had subjectively resolved within 12 days of admission after nutritional rehabilitation and weight gain.

Conclusion

Transient autophony in severe AN patients is due to PET, and was present in at least 8% of patients within our cohort. Further study is warranted to understand the quality of life impact and pathophysiology of transient PET in this patient population.

Eustachian Tube Dysfunction Improvement Secondary to Moderate Weight Loss: Case Report

The Eustachian tube (ET) is an osteocartilaginous canal that connects the middle ear to the nasopharynx. It is one of the critical structures essential for middle ear functions. ET dysfunction causes discomfort in the affected ear and decreased hearing. This is the first case report of improving hearing and middle ear aeration and ET function secondary to body weight reduction. A 27-year-old male patient presented to the otology clinic complaining of decreased hearing for two years. Initial ear examination revealed retraction of TM on the left ear with two retraction pockets, and on the right ear, the TM was dull with one retraction pocket. The patient reported losing some of his body weight during those six months. Ear examination revealed improvement in the TM retraction in both ears. The improvement in hearing was evidenced by a serial audiogram, while the middle ear aeration was evidenced by clinical examination.

Enlargement of Eustachian Tube Lumen in Patulous Eustachian Tube Patients Compared to that by Aging

OBJECTIVE

To evaluate the Eustachian tube (ET) dimensions in patulous ET (PET) patients compared with that by aging using sitting 3D computed tomography (CT).

STUDY DESIGN

Retrospective study.

SETTING

Tertiary referral center.

SUBJECTS AND METHODS

A retrospective survey of medical records in Sen-En Rifu Hospital identified 105 ears of 76 PET patients and 65 ears of 34 patients without ET dysfunction findings (non-PET). Subjects in both PET and non-PET groups were then divided into two age groups. Groups A and C defined as non-PET and PET subjects respectively, who were under the age of 60 years, while Groups B and D defined of non-PET and PET subjects respectively, who were 60 years and above. 3D CT (Accuitomo; Morita, Kyoto, Japan) was performed on all subjects in the sitting position. The ET lumen from the ET pharyngeal orifice to 15 mm was analyzed.

RESULTS

No significant difference in the ET lumen near the pharyngeal orifice was found between Group A and C; however, there was a significant difference in the ET at points lateral to the pharyngeal orifice. The ET lumen was significantly larger at the site close to the pharyngeal orifice in Group B as compared to that of Group A. For the two groups of PET classified according to the size of the pharyngeal orifice and area close to the isthmus, age was only significantly different between two groups of pharyngeal orifice. On the contrary, sonotumometry and Ohta method were significantly different between the two groups of the area close to the isthmus.

CONCLUSION

The lumen of the ET is enlarged in both PET and aging. However, the responsible site was found to be different. While the enlargement of the ET lumen in 60 years and above subjects without PET mainly occurred near the pharyngeal orifice of the ET, it was near the isthmus in under 60 years PET patients. Further study of possible clinical implications of these findings as well as treatment strategy are required.

Autophony in inpatients with anorexia nervosa or avoidant restrictive food intake disorder

OBJECTIVE

To assess for the prevalence of autophony, a distressing auditory symptom commonly attributed to patulous eustachian tube, in a cohort of individuals with severe malnourishment due to an eating disorder.

METHOD

A cross-sectional survey study was performed. Patients admitted for inpatient medical stabilization of an eating disorder, who were also at low body weight, were asked to complete a survey assessing aural symptoms present in the previous 24 hr, including autophony. Anthropometric data and prealbumin levels were collected.

RESULTS

Of 101 patients enrolled, 43 (42.6%) reported symptoms of autophony. The presence of autophony was associated with lower serum prealbumin levels and lower body weight as measured by percentage of ideal body weight.

DISCUSSION

Autophony is a commonly reported, albeit rarely discussed, symptom in individuals with severe eating disorders and correlates with degree of malnutrition.

Hearing Dysfunction After Treatment With Teprotumumab for Thyroid Eye Disease

PURPOSE

To characterize the frequency, severity, and resolution of hearing dysfunction in patients treated with teprotumumab for thyroid eye disease (TED).

DESIGN

Prospective observational case series.

METHODS

Ophthalmic examination and adverse event assessment, including otologic symptoms, were performed at baseline, after infusions 2, 4, and 8, and at 6-month follow-up in consecutive patients who received at least 4 teprotumumab infusions. Laboratory test results were collected at baseline and during treatment. Audiometry, patulous eustachian tube (PET) testing, and otolaryngology evaluation were obtained for patients with new or worsening otologic symptoms, with a subset obtaining baseline and posttreatment testing.

RESULTS

Twenty-seven patients were analyzed (24 females, 3 males, average 56.3 years old). Twenty-two patients (81.5%) developed new subjective otologic symptoms, after a mean of 3.8 infusions (SD 1.8). At 39.2-week average follow-up after the last infusion, most patients with tinnitus (100%), ear plugging/fullness (90.9%), and autophony (83.3%) experienced symptom resolution, whereas only 45.5% (5 of 11) of patients with subjective hearing loss/decreased word comprehension experienced resolution. Six patients underwent baseline and posttreatment audiometry, 5 of whom developed teprotumumab-related sensorineural hearing loss (SNHL) and 1 patient also developed PET. Three of the 5 patients with teprotumumab-related SNHL had persistent subjective hearing loss at last follow-up. A prior history of hearing loss was discovered as a risk factor for teprotumumab-related SNHL (P = .008).

CONCLUSIONS

Hearing loss is a concerning adverse event of teprotumumab, and its mechanism and reversibility should be further studied. Until risk factors for hearing loss are better understood, we recommend baseline audiometry with PET testing and repeat testing if new otologic symptoms develop. Screening, monitoring, and prevention guidelines are needed.

Post-traumatic temporal bone pneumatocele presenting after aggressive Valsalva

We report a case of a temporal bone pneumatocele with full-thickness erosion of the cranium associated with aggressive nose blowing. This condition presented 9 years after traumatic fracture of the temporal bone. There are 17 reported cases of mastoid sinus hyperpneumatisation in the literature. Eleven of the 17 are associated with Valsalva manoeuvres or elevated middle ear pressure. However, no other cases of full-thickness erosion at the site of a former fracture have been reported. We propose that the fracture, in combination with elevated mastoid sinus pressure from aggressive nose blowing, led to escape and trapping of pressurised air in the epidural and subcutaneous spaces, which resulted in bone erosion.

Transtympanic Tripod-shaped Angiocatheter Insertion for Patients With Intractable Patulous Eustachian Tube

OBJECTIVE

Despite the efforts to treat patients with patulous Eustachian tube (PET), intractable symptoms of PET may require surgical intervention. In this study, we introduce our surgical technique of "transtympanic tripod-shaped angiocatheter" (TTA) insertion and evaluate the safety and efficacy of the procedure in patients with intractable PET.

STUDY DESIGN

Retrospective chart review.

SETTING

Tertiary referral center.

PATIENTS

Thirty-two cases (26 patients) diagnosed with intractable PET between the years 2011 and 2019 were included in this study.

INTERVENTION

All cases were surgically treated with TTA insertion.

MAIN OUTCOME MEASURES

The clinical characteristics, surgical results, complication rates, and the level of satisfaction by questionnaires were analyzed for evaluation.

RESULTS

The mean age of enrolled patients was 40.9 ± 19.5 years, with slight male gender predominance (59.4% vs. 40.6%). Both ears were operated in six patients, simultaneously in three. All patients successfully received the insertion of TTA, with no immediate complication. Eleven cases were re-inserted after the first insertion due to the recurrence of symptoms or spontaneous extrusion of TTA. No major complications were observed during the follow-up period of 1 to 115 months (mean 37.7 mo). The average Visual Analogue Scale score of PET symptoms was significantly decreased (p < 0.05), along with 92% of patients with relief from autophony symptoms.

CONCLUSIONS

TTA insertion is a relatively simple procedure that can be performed in a short period under local anesthesia. Surgical intervention of TTA insertion for patients with intractable PET symptoms seems promising with a high success rate.

Patulous Eustachian Tube Patients With Respiratory Fluctuation of Tympanic Membrane in Both Sitting and Supine Positions: A Sign of Severity of Disease?

OBJECTIVE

The aim is to report four cases of patulous Eustachian tube (PET) patients with respiratory fluctuation of the tympanic membrane (TM) even in the supine position, and to examine the frequency and characteristics of such patients.

PATIENTS

There were 195 ears (99 right ears and 96 left ears) from 146 cases (56 male and 90 female subjects aged 8-88, average 48.0 ± 18.9 yrs) diagnosed with definite PET by diagnostic criteria proposed by Japan Otologic Society (JOS) between January 2017 and December 2019 at Sen-En Rifu Hospital. Patients who presented with respiratory fluctuation of the TM in both the sitting and supine positions were examined.

MAIN OUTCOME MEASURES

Clinical patient records, the severity of subjective symptoms (PET handicap inventory-10 [PHI-10]), objective ET function tests (tubo-tympano-aerodynamic graphy [TTAG] and sonotubometry), and sitting three-dimensional computed tomography (3-D CT) were analyzed.

RESULTS

Six ears (3.1%) of four cases (2.7%) exhibited respiratory fluctuation of the TM, even in the supine position. In these six ears (four cases), the PHI-10 score ranged from 16 to 36 with three ears exhibiting PHI-10 score equal to or exceeding 26 (in the category of severe handicap). Sitting CT indicated the findings of completely open ET in only two ears. All ears but one were managed by conservative treatment.

CONCLUSION

Respiratory fluctuation of the TM in both the sitting and supine positions was observed in 2.7% of the definite PET patients. Surprisingly, such findings can be an indication of neither the subjective nor objective severity of the disease. Therefore, even for PET patients with such findings, surgery should not be immediately proposed, but rather, conservative management should be undertaken first.

Seasonal variation of patulous Eustachian tube diagnoses using climatic and national health insurance data

OBJECTIVES

This study aimed to analyse if there were any associations between patulous Eustachian tube occurrence and climatic factors and seasonality.

METHODS

The correlation between the monthly average number of patients diagnosed with patulous Eustachian tube and climatic factors in Seoul, Korea, from January 2010 to December 2016, was statistically analysed using national data sets.

RESULTS

The relative risk for patulous Eustachian tube occurrence according to season was significantly higher in summer and autumn, and lower in winter than in spring (relative risk (95 per cent confidence interval): 1.334 (1.267-1.404), 1.219 (1.157-1.285) and 0.889 (0.840-0.941) for summer, autumn and winter, respectively). Temperature, atmospheric pressure and relative humidity had a moderate positive (r = 0.648), negative (r = -0.601) and positive (r = 0.492) correlation with the number of patulous Eustachian tube cases, respectively.

CONCLUSION

The number of patulous Eustachian tube cases was highest in summer and increased in proportion to changes in temperature and humidity, which could be due to physiological changes caused by climatic factors or diet trends.

[Evaluation of standardized questionnaires for diagnosis and differentiation of obstructive and patulous Eustachian tube dysfunction]

Hintergrund

Eine klaffende Tube kann insbesondere durch Autophonie, Druckgefühl und gestörten Höreindruck zu einer Einschränkung der Lebensqualität führen. Bei fehlenden spezifischen Symptomen kann die Diagnose der klaffenden Tube schwierig sein. Insbesondere die Abgrenzung zur chronisch obstruktiven Tubenfunktionsstörung stellt eine Herausforderung dar. Da derzeit kaum standardisierte Diagnostik- und Therapieoptionen zur Verfügung stehen, ist eine strukturierte Untersuchung zur sicheren Diagnostik und wissenschaftlichen Aufarbeitung dieser Erkrankung erforderlich. Für die Diagnostik der chronisch obstruktiven Tubenfunktionsstörung wurde 2012 bereits der „Eustachian Tube Dysfunction Questionnaire“ (ETDQ-7-Fragebogen) nach McCoul entwickelt. Für die klaffende Tube existiert seit 2017 der PHI-10-Fragebogen („patulous Eustachian tube handicap inventory“) nach Kobayashi.

Material und Methoden

Der PHI-10-Fragebogen wurde ins Deutsche übersetzt und an 41 Gesunden, 13 Patienten mit Tinnitus auris, 11 Patienten mit klaffender Tube und 18 Patienten mit chronisch obstruktiver Tubenventilationsstörung getestet. Zusätzlich erfolgte im Vergleich die Auswertung des ETDQ‑7 nach McCoul.

Ergebnisse

Es erfolgt die Präsentation der deutschen Übersetzung des PHI-10 und der Ergebnisse von PHI-10 und ETDQ‑7 in allen Patientengruppen. Der ETDQ‑7 hat das Risiko falsch-positiver Ergebnisse bei Patienten mit klaffender Tube und der PHI-10 bei Patienten mit obstruktiver Tubenfunktionsstörung. Beide untersuchten Fragebögen sind falsch-positiv bei Tinnituspatienten.

Schlussfolgerung

Der PHI-10 (deutsch) und ETDQ‑7 (deutsch) sind eine nützliche Unterstützung der Anamnese bezüglich Tubenfunktionsstörungen. Sie unterscheiden jedoch nur unzureichend zwischen klaffenden und obstruktiven Tubenfunktionsstörungen und eignen sich nicht für Patienten mit Tinnitus. Die Stärke der Fragebögen ist in der Verlaufskontrolle und dem Monitoring von Therapieergebnissen zu sehen.

A novel technique for patulous Eustachian tube augmentation

OBJECTIVE

To determine the effectiveness of a soft-tissue bulking agent comparing novel approaches of Eustachian tube (ET) augmentation procedures: transpalatinatal Eustachian tube augmentation in local and general anesthesia versus an augmentation with velotraction under general anesthesia. The clinical endpoint was the resolution of symptoms related to unilateral patulous Eustachian tube dysfunction (PETD) requiring no additional revision augmentations.

STUDY DESIGN

Combined retrospective clinical chart review.

SETTING

Tertiary referral center.

METHODS

Patients suffering from PETD underwent one of the following procedures: Group (A) transpalatinatal soft-tissue bulking agent with infiltration/augmentation under local anesthesia in a sitting position, group (B) transpalatinatal soft-tissue bulking agent infiltration/augmentation under general anesthesia in the flat position or group (C) infiltration/transoral augmentation of the ET with velotraction under general anesthesia in a flat position. The requirement to repeat the procedure due to recurrence of any PETD-related symptoms was recorded and retrospectively analyzed.

RESULTS

A total of 50 procedures were executed in 50 patients with unilateral PETD. The necessity to perform a second procedure has analyzed a mean of 6 months postoperatively (range: 6-17 months). Compared to the transpalatinatal augmentation in local anesthesia (group A) (100% success rate), the 6-month failure rate was significantly higher for transpalatinatal augmentation under general anesthesia (group B) (80% success rate) and velotraction augmentation under general anesthesia (group C) (67% success rate). Patient cohort with transpalatinatal augmentation under general anesthesia required 20% and augmentation with velotraction under general anesthesia in 33% revision augmentation procedures reviewed at 6 months follow-up (mean follow-up 11.2 months).

CONCLUSIONS

Although all different approaches resulted in a reduction of PETD related symptoms, the transpalatinatal ET augmentation in local anesthesia achieved a statistically significant superior clinical improvement. A complete resolution of PETD related symptoms was obtained and required additional procedures. This improvement may be related to the intraoperative "feedback" by the patients in local anesthesia in the sitting position eliminating the necessity for repeated procedures.

The impact of bariatric surgery on eustachian tube dysfunction

PURPOSE

We aimed to evaluate the relationship between acute loss of weight after 6 months of bariatric surgery and the occurrence of tubal dysfunction symptoms METHODS: We recruited 76 patients who had undergone bariatric surgery between 2018 and 2019. It was planned to see if the change in Body Mass Index (BMI) caused changes in the Eustachian Tube Dysfunction Questionnaire (ETDQ-7) scores of individuals. Regardless of the questionnaire, patients were also asked for 3 symptoms (autophony, fullness in the ear, hearing their own breath in the ear) before and 6 months after bariatric surgery.

RESULTS

The mean age of the study group was 39.32 ± 11.09 years and 80.3% percent of the patients were female. The mean weight loss of the patients at the 6th month was 44.67 ± 13.10 kg, and mean weight loss rate was % 35.06 ± 8.01. The incidence of hearing their own breath, autophony and fullness of the ear were 25%, 22.4% and 11.8%, respectively. The proportion of those experiencing any of these three complaints was 30.3% (n = 23). The ETDQ scores of the cases ranged from 7 to 27, with an average of 9.38 ± 4.28. There are 10.5% (n = 8) paints with a score of ≥ 14.5 as regarded as patients with Eustachian tube dysfunction (ETD). The mean age of patients with ETD was significantly higher (p < 0.05) than patients without ETD. Gender distributions, weight loss rates, smoking, previous operation and additional disease distributions do not show statistically significant differences between patients with and without ETD (p > 0.05).

CONCLUSION

Present study indicated a 10.5% ETD incidence after bariatric surgery. ETDQ questionnaire can be used for ETD screening in patients who underwent bariatric surgery, which will be an overlooked complication in this group of subjects.

Current Treatment Options for Patulous Eustachian Tube: A Review of the Literature

OBJECTIVE

Patulous Eustachian tube (PET) is a clinical condition that is associated with troublesome aural symptoms and is difficult to be treated successfully. The purpose of this review is to examine the published literature regarding the therapeutic value of the current treatment options for PET.

METHODS

We searched Web of Science, PubMed and Medline from 1999 to 2019. The search focused on papers concerning the clinical evaluation of treatment methods in PET patients. Statistical techniques were not used.

RESULTS

Prospective and retrospective case series were the types of trials available for review. We included 28 articles that evaluated the efficacy of various conservative and surgical therapeutic options. The recovery rates ranged from 50% to 100%. In most studies the assessment of efficacy was based on the subjective improvement of patient symptoms as there is no validated outcome tool available. No severe adverse events were observed in any study.

CONCLUSION

On the basis of the available literature, it seems that conservative treatments can be considered as a primary therapeutic option for PET. Concerning the surgical interventions they seem to be a safe and valuable solution in patients with refractory disease. Finally, given the low level of evidence, prospective case-control studies with long follow-up and robust setting looking into the therapeutic approach of PET are required. The need for establishment of standard criteria of PET recovery should be underlined.

Comparison of patulous Eustachian tube patients with and without a concave defect in the anterolateral wall of the tubal valve

OBJECTIVE

Patulous Eustachian tube appears to be caused by a concave defect in the anterolateral wall of the tubal valve of the Eustachian tube. This study aimed to compare the clinical features of patulous Eustachian tube patients with or without a defect in the anterolateral wall of the tubal valve.

METHODS

Sixty-six patients with a patulous Eustachian tube completed a questionnaire, which was evaluated alongside endoscopic findings of the tympanic membrane, nasal cavity and Eustachian tube orifice.

RESULTS

Females were more frequently diagnosed with a patulous Eustachian tube, but the valve defect was more common in males (p = 0.007). The ratio of patulous Eustachian tube patients with or without defects in the anterolateral wall of the tubal valve was 1.6:1. Weight loss in the previous six months and being refractory to conservative management were significantly associated with the defect (p = 0.035 and 0.037, respectively). Symptom severity was significantly higher in patients with the defect.

CONCLUSION

Patulous Eustachian tube patients without a defect in the anterolateral wall of the tubal valve can be non-surgically treated more often than those with the defect. Identification of the defect could assist in making treatment decisions for patulous Eustachian tube patients.

Diagnostic approaches to and management options for patulous eustachian tube

OBJECTIVES

To systematically review the literature and to summarize all evidence related to the diagnosis and management of patulous eustachian tube.

METHODS

The present study was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement.

RESULTS

Overall, 59 articles were retrieved and included in the analysis. Studies investigating treatments enrolled 1279 patients collectively, with follow-up duration varying from few days and up to 2 years. Eight studies reported medical treatments with intranasal saline instillation as the most frequently studied option. Other studies reported various surgical treatments varying from simple tympanostomy to invasive procedures targeting the orifice of the ET or the anatomical features surrounding it. In addition, 10 studies including 367 subjects investigated different diagnostic methods.

CONCLUSION

Currently, there is a wide spectrum of diagnostic and therapeutic interventions with minimal clinical efficacy, a persistent lack of systematic guidelines, and several gaps in previous research endeavours.

Patulous Eustachian tube and palatine defect in a Dachshund with chronic unilateral otitis externa and otitis media

BACKGROUND

Patulous Eustachian tube (pET) is a rare dysfunction of the Eustachian tube described in humans. It is characterized by failure of the ET to close, resulting in unrestricted passage of air, sound and material between the nasopharynx and the middle ear.

OBJECTIVE

To report a case of pET associated with otitis in a dog.

ANIMAL

A 6-year old-female spayed Dachshund dog.

METHODS AND MATERIALS

Otoscopic examination, cytological evaluation, culture and susceptibility, computerized tomography (CT), video-otoscopic flushing and surgery.

RESULTS

Left ear otoscopic examination revealed erythema, purulent frothy discharge, ceruminous gland hyperplasia, stenosis and a partial tear of the tympanum. Cytological evaluation from the left external canal showed neutrophils, macrophages, rods and cocci. Aerobic culture showed predominantly multidrug-resistant Pseudomonas aeruginosa. The CT findings of the left ear included chronic changes in the external canal, marked lysis of the tympanic bulla and marked dilation of the ET. During video-otoscope flushing, saline drained through the mouth. Bilateral incomplete hypoplasia of the soft palate was noted. Total ear canal ablation and bulla osteotomy with ET dissection were curative. Histopathological findings were compatible with chronic otitis externa (OE) and media.

CONCLUSION AND CLINICAL IMPORTANCE

To the best of the authors' knowledge, this is the first case of pET described in animals. The ET dysfunction and palatine defect were likely the cause of the otitis in this dog. Clinicians should investigate pET in animals with signs of OE characterized by frothy liquid and food fragments in the ear canal in addition to sneezing after drinking water.

Positional Vertigo and Unilateral Gradual Hearing Loss Following Sleeve Gastrectomy: A Case Report

Laparoscopic sleeve gastrectomy (LSG) is an effective treatment option in patients with morbid obesity, with rare long-term sideeffects. In this report, we present a 42-year-old woman who reported positional vertigo and unilateral gradual hearing loss plus continuous tinnitus after LSG. The patient had no signs or symptoms of mental health disorders and the results of the haematological and serum biochemical tests were normal. However, audiometric test revealed mild sensorineural hearing loss with magnitude in high-frequency tones. Also, acoustic reflex threshold showed neural pathway damage, particularly at high frequencies, with no reflex. Pure tone audiometry showed signs of nerve damage in the inner ear. One possible justification for these complications might be eustachian tube dysfunction due to muscle relaxation. Muscle relaxation itself may occur as a result of adipose tissue loss around the ear muscles. Further evidence, however, would be required to better determine whether these complications are attributable to LSG, and to illuminate exact underlying reasons for such complications.

The characteristic of patulous eustachian tube patients diagnosed by the JOS diagnostic criteria

Objective

The objective is to describe characteristics of patients diagnosed with patulous Eustachian tube (PET) using the Diagnostic Criteria proposed by Japan Otological Society, and to evaluate the efficiency of objective tests to determine patent Eustachian tube.

Study design

Retrospective.

Setting

Tertiary referral center.

Subjects

A retrospective survey of medical records in Sen-En Rifu Hospital identified 78 ears of 56 patients with “Definite PET” diagnosed by the JOS Diagnostic Criteria between January 2017 and December 2017.

Method

Initial diagnosis, aural symptoms (voice autophony, aural fullness and breathing autophony), tubal obstruction procedures (posture change and pharyngeal orifice obstruction) and objective findings (tympanic membrane movement, Tubo-Tympano-Aerodynamic Graphy (TTAG) and sonotubometry) were evaluated. In addition, sonotubometry with postural change (Ohta’s method), sitting CT and a newly devised PHI-10 score were also examined.

Results

Voice autophony, aural fullness, and breathing autophony were observed in 93.6%, 87.2%, 78.2%, respectively. In 91% of the ears, PET symptoms improved by postural change from sitting to the lying / forward-bending position. Synchronous movement of the TM upon respiration was observed in 69.1% of the ears. Positive findings of TTAG were observed in 75.6% of ears. Positive findings of sonotubometry were found in 55.1% of ears. Sonotubometry with postural change (Ohta’s method), when the cut-off value of over 10dB was used, was positive in 45.2% of ears. Newly devised PHI-10 score representing severity of subjective symptoms classifying patients into no handicap, mild handicap, moderate handicap and severe handicap were observed in 12.2%, 10.8%, 18.9% and 58.1% of ears, respectively. The evaluation of the extent of patency of the ET by sitting CT indicated completely open, closed-short, and closed-long, in 68.6%, 11.4% and 21.4% of ears, respectively. Compared to the closed group, the completely open group had a significantly higher frequency of positive breathing autophony, positive sonotubometry, and positive Ohta’s method.

Conclusion

The characteristics of main symptoms and the efficiency of various tests in PET diagnosis were analyzed based on data obtained from “Definite PET” patients diagnosed by the JOS Diagnostic Criteria. The greater the availability of tests to evaluate PET, the greater the opportunities to diagnose “Definite PET”. In particular, tests measuring pressure transmission between the nasopharynx and middle ear, such as TM observation and TTAG, are more sensitive than sonotubometry measuring sound transmission.

The Performance of Patient-reported Outcome Measures as Diagnostic Tools for Eustachian Tube Dysfunction

OBJECTIVE

To develop and validate a novel patient-reported outcome measure (PROM) to distinguish patulous from obstructive Eustachian Tube Dysfunction (ETD). To determine accuracy of PROMs and ET function tests as diagnostic tools for ETD.

STUDY DESIGN

1) PROM development and validation. 2) Test case-control diagnostic accuracy study.

INTERVENTIONS

Cambridge ETD Assessment (CETDA) and ETDQ-7 PROMs, sonotubometry and tubomanometry ET function tests.

SETTING

Tertiary referral center.

PATIENTS

Cases with patulous (n = 7) or obstructive (n = 60) ETD, controls with either no ear symptoms (n = 33), or symptoms arising from hearing loss or Menière's disease (n = 24).

MAIN OUTCOME MEASURES

PROMs were assessed in terms of internal consistency, ceiling and floor effects, test-retest reliability and content, structural and criterion validity. PROMs and function test sensitivity and specificity was determined as diagnostic tests for ETD.

RESULTS

The 10-item CETDA was developed. CETDA validity and performance were good, though five items suffered floor effects. There was no difference in scores for either PROM in the patulous ETD, obstructive ETD, and symptomatic control groups. Both PROMS had excellent diagnostic accuracy using only healthy controls as comparator for ETD, but specificity was very poor when controls with other otological disorders were included. Both objective tests had sensitivity and specificity of 63% and 79% for obstructive ETD.

CONCLUSIONS

The CETDA and ETDQ-7 are not disease-specific and cannot distinguish obstructive from patulous ETD subtypes. A relatively weak correlation between sonotubometry and tubomanometry results, PROM scores, and the clinical diagnosis suggests that a varied core set of outcome measures is required to monitor response to treatments for ETD.

Advances in Eustachian tube function testing

Obstructive and patulous Eustachian tube dysfunction provide a significant diagnostic and management challenge. The development of new treatments such as balloon Eustachian tuboplasty has generated renewed interest in measuring Eustachian tube function, as a method of selecting appropriate patients for intervention, and measuring their treatment outcomes.

This review summarises recent findings relating to Eustachian tube function assessment. Increasingly it is recognised that patient reported outcome measures based on symptoms are highly non-specific and non-diagnostic, and clinical assessment alone may not permit the selection of individuals with abnormal Eustachian tube opening. Tests of Eustachian tube opening therefore may represent a practical and objective addition to patient assessment in clinic, allowing the identification of individuals with abnormal (patulous or obstructive) Eustachian tube function. A diagnostic pathway is described on this basis.

More work is required to validate the described Eustachian tube function tests, and there remain individuals, such as those with dysfunction limited to pressure challenges, in whom function tests have yet to fully characterise the disorder.

Plug size selection protocol for the treatment of intractable patulous Eustachian tube with Kobayashi Plug

Background: There have been no useful criteria for initial plug size selection protocol for the treatment of intractable patulous Eustachian tube (PET). Aims/objectives: To establish a method for appropriate plug size selection using tubal function test and subjective symptom severity in PET patients who were treated by Kobayashi Plug insertion. Material and methods: A retrospective survey of medical records identified 39 ears of 35 patients with PET who received insertion of the Kobayashi Plug and whose PET symptoms were thereafter controlled for at least 6 months after surgery. Method: The evaluation scale of PET handicap inventory-10 (PHI-10) was used to indicate PET subjective symptom severity. Tubal function tests (sonotubometry and tubo-tympano-aerodynamic-graphy: TTAG) were performed. Results: There was no correlation between the preoperative PHI 10 score and plug size (p = .157). There was a significant correlation between the preoperative sound attenuation from nostril to EAC measured by sonotubometry and plug size (p < .001). There was no correlation between the preoperative pressure transmission ratio estimated by TTAG and plug size (p = .271). Conclusions and Significance: Sonotubometry which evaluates sound attenuation from nostril to EAC can be a useful tool for selecting plug size.

Efficacy of a silicone plug for patulous eustachian tube: A prospective, multicenter case series

OBJECTIVES/HYPOTHESIS

To report the efficacy and safety of transtympanic plugging of the eustachian tube (ET) using a silicone plug (Kobayashi plug) for chronic patulous ET (PET).

STUDY DESIGN

Prospective and multicenter trial conducted in which 30 PET patients were resistant to at least 6 months of conservative treatment.

METHODS

The efficacy and safety of 28 and 27 patients, respectively, were analyzed. All patients fulfilled inclusion and exclusion criteria. The primary end point used the patulous eustachian tube handicap inventory-10 (PHI-10), and the secondary end point used ET function tests such as sonotubometry, tubo-tympano-aerodynamic-graphy, and respiratory movement of the tympanic membrane and auscultation of voice sounds transmitted from the nose through the ET to the external auditory canal at 3months after surgery.

RESULTS

PHI-10 scores were 34.4 ± 4.2, 6.4 ± 9, and 5.7 ± 8.6 at screening, and 3 and 6 months after surgery. Twenty-three cases (82.1%, 95% confidence interval: 63.1%-93.9%) were judged as successes. There were five cases (17.2%) of middle ear effusion, four cases (13.8%) of tympanic membrane perforation, and one case of tinnitus due to surgery to remove the plug. No severe or life-threatening complications were found.

CONCLUSIONS

This study revealed the efficacy and safety of silicone plug insertion for severe PET patients.

LEVEL OF EVIDENCE

2 Laryngoscope, 130:1304-1309, 2020.

Clinical Consensus Statement: Balloon Dilation of the Eustachian Tube

OBJECTIVE

To develop a clinical consensus statement on the use of balloon dilation of the eustachian tube (BDET).

METHODS

An expert panel of otolaryngologists was assembled with nominated representatives of general otolaryngology and relevant subspecialty societies. The target population was adults 18 years or older who are candidates for BDET because of obstructive eustachian tube dysfunction (OETD) in 1 or both ears for 3 months or longer that significantly affects quality of life or functional health status. A modified Delphi method was used to distill expert opinion into clinical statements that met a standardized definition of consensus.

RESULTS

After 3 iterative Delphi method surveys, 28 statements met the predefined criteria for consensus, while 28 statements did not. The clinical statements were grouped into 3 categories for the purposes of presentation and discussion: (1) patient criteria, (2) perioperative considerations, and (3) outcomes.

CONCLUSION

This panel reached consensus on several statements that clarify diagnosis and perioperative management of OETD. Lack of consensus on other statements likely reflects knowledge gaps regarding the role of BDET in managing OETD. Expert panel consensus may provide helpful information for the otolaryngologist considering the use of BDET for the management of patients with OETD.

Eustachian tuboplasty and shrinkage of ostial mucosa with new devices : Including a proposal of a classification system

OBJECTIVE

A new combined approach to Eustachian tube dysfunction (ETD) employing new minimally invasive devices is described.

STUDY DESIGN

An anatomoclinical classification of ETD was conceived to allow correct categorization of patients and enable comparative studies to be performed. Herein, the authors report on their experience with a consecutive series of obstructive ETD patients treated by balloon dilation of the Eustachian tube using AERA (Acclarent, Menlo Park, CA, USA), combined with a quantic molecular resonance (QMR)-mediated rhinopharyngeal tubal ostial mucosa shrinkage technique with a dedicated "Mitto" hand piece (Telea, Sandrigo-Vicenza, Italy).

METHODS

A prospective study was conducted in 102 patients with ETD. Medical history, complete clinical ENT evaluation and oto-functional examinations were performed in all patients. In all cases, balloon dilatation of the Eustachian tube was performed via the transnasal approach under video-endoscopic control. This was followed by decongestion of the torus tubarius and the inferior turbinate by QMR, with immediate shrinkage of the mucosa of the turbinate and a reduction of the prolapse of the mucosal plica on the tubal ostium.

RESULTS

Comparison of pre- and postoperative oto-functional examinations revealed a significant improvement. The postoperative hearing symptoms were reduced in a statistically significant manner on the visual analog scale (VAS). It was possible to perform the postoperative "swallowing-opening-Toynbee-Valsalva" (SOTV) test in a significant percentage of cases compared to the preoperative test.

CONCLUSION

The combined surgical procedure of balloon tubodilation with simultaneous QMR-mediated shrinkage of the tubal ostial mucosa and reduction of the posterior portion of the inferior turbinate was found to be an effective, safe, and complete treatment for tubal dysfunction in the majority of patients.

Management of Acquired Cholesteatoma Associated With Patulous Eustachian Tube and Habitual Sniffing

OBJECTIVES

To investigate the effect of surgical treatment with eustachian tube (ET) catheter insertion in patients with acquired cholesteatoma associated with patulous eustachian tube (PET) and habitual sniffing.

METHODS

Nine ears of nine patients (two men and seven women; age, 20 to 65 years; average, 37.9±12.0 years) of acquired cholesteatoma associated with PET and habitual sniffing who underwent cholesteatoma surgery with simultaneous additional ET catheter insertion were examined in this study. Successful treatment was defined as stoppage of sniffing, a relief of a PET handicap inventory-10 (PHI-10), an improvement of autophony grade and no cholesteatoma recurrence.

RESULTS

ET catheter insertion was performed in all ears. Follow-up duration ranged from 16 to 37 months (average, 25.4 months). Cases consisted of nine pars flaccida type (100%). All patients obtained relief from aural symptoms and stopped sniffing. Postoperative PHI-10 scores were significantly lower than preoperative scores (P<0.001). During an average follow-up of 25.4 months, no cholesteatoma recurrence has occurred to date. One patient developed otitis media with effusion (OME) post-catheterization; OME resolved spontaneously without treatment. Four patients had a consecutive ET catheter insertion on the other side to resolve PET-related aural symptoms.

CONCLUSION

In case of acquired cholesteatoma with PET and habitual sniffing, ET catheter insertion performed simultaneously with cholesteatoma surgery could help reduce aural symptoms and stop sniffing. Moreover, the procedure might help in preventing cholesteatoma recurrence.

A novel computed tomography guided, transcutaneous approach to treat refractory autophony in patients with a patulous Eustachian tube - a case series

BACKGROUND

Patulous Eustachian tube is a benign but notoriously difficult condition to treat successfully. Symptoms include autophony of voice and breathing, and aural fullness.

METHODS

This paper presents a series of 8 patients (12 ears) for whom a novel computed tomography guided injection of silicone elastomer suspension implant (Vox) was used to treat patulous Eustachian tube. This is the largest and only series in the current literature using this technique.

RESULTS

The combined complete and partial symptom resolution rate was 91 per cent. Complications related to the procedure are described. The pros and cons of this novel approach are also discussed in relation to traditional endoscopic transnasal techniques.

CONCLUSION

Computed tomography guided injection of Vox for the treatment of patulous Eustachian tube is suggested to be a feasible alternative to endoscopic transnasal approaches, particularly for refractory cases.

Eustachian tube dysfunction: A diagnostic accuracy study and proposed diagnostic pathway

Background and aims

Eustachian tube dysfunction (ETD) is a commonly diagnosed disorder of Eustachian tube opening and closure, which may be associated with severe symptoms and middle ear disease. Currently the diagnosis of obstructive and patulous forms of ETD is primarily based on non-specific symptoms or examination findings, rather than measurement of the underlying function of the Eustachian tube. This has proved problematic when selecting patients for treatment, and when designing trial inclusion criteria and outcomes. This study aims to determine the correlation and diagnostic value of various tests of ET opening and patient reported outcome measures (PROMs), in order to generate a recommended diagnostic pathway for ETD.

Methods

Index tests included two PROMs and 14 tests of ET opening (nine for obstructive, five for patulous ETD). In the absence of an accepted reference standard two methods were adopted to establish index test accuracy: expert panel diagnosis and latent class analysis. Index test results were assessed with Pearson correlation and principle component analysis, and test accuracy was determined. Logistic regression models assessed the predictive value of grouped test results.

Results

The expert panel diagnosis and PROMs results correlated with each other, but not with ET function measured by tests of ET opening. All index tests were found to be feasible in clinic, and acceptable to patients. PROMs had very poor specificity, and no diagnostic value. Combining the results of tests of ET function appeared beneficial. The latent class model suggested tympanometry, sonotubometry and tubomanometry have the best diagnostic performance for obstructive ETD, and these are included in a proposed diagnostic pathway.

Conclusions

ETD should be diagnosed on the basis of clinical assessment and tests of ET opening, as PROMs have no diagnostic value. Currently diagnostic uncertainty exists for some patients who appear to have intermittent ETD clinically, but have negative index test results.

Chronic Ear Disease

Chronic ear disease is composed of a spectrum of otologic disorders intrinsically tied to Eustachian tube dysfunction. Presentation can range from asymptomatic findings on physical examination to critically ill patients with intracranial complications. Internists represent the first line in diagnosis of these conditions, making awareness of the common signs and symptoms essential. With surgical management often required, partnership between internal medicine and otolaryngology is fundamental in the management of patients with chronic ear disease.